Provider Demographics
NPI:1972361996
Name:ARDIANTO, SUMMER BREEAYN
Entity Type:Individual
Prefix:
First Name:SUMMER
Middle Name:BREEAYN
Last Name:ARDIANTO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:CANBY
Mailing Address - State:OR
Mailing Address - Zip Code:97013-3519
Mailing Address - Country:US
Mailing Address - Phone:503-263-8903
Mailing Address - Fax:503-266-8632
Practice Address - Street 1:2274 SW 2ND ST STE D
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-5597
Practice Address - Country:US
Practice Address - Phone:503-372-5147
Practice Address - Fax:503-266-8632
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-13
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health